| NPI | 1477781813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: NC 12792) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4211) |
| 1223G0001X Dentist, General Practice (Licence: NC 12792) | |
| Enumeration Date | 2009-06-24 |
| Last Update Date | 2022-06-29 |